Can Action Research Strengthen District Health Management and Improve Health Workforce Performance? A Research Protocol.

The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance

Work stress and hair cortisol levels among workers in a Bangladeshi ready-made garment factory - results from a cross-sectional study

SummaryEvidence on the association of work stress with cortisol levels is inconsistent and mostly stems from Western countries, with limited generalizability to other regions of the world. These inconsistencies may partly be due to methodological limitations associated with the measurement of cortisol secretion in saliva, serum or urine. The present study set out to explore associations of work stress with long-term integrated cortisol levels in hair among 175 workers of an export oriented ready-made garment (RMG) factory in Dhaka, Bangladesh.Work-related demands (WD), interpersonal resources (IR) and work-related values (WV) were assessed using a psychometrically evaluated interview. WD consisted of four items on physical demands, time pressure, worries about mistakes and exposure to abusive language. IR comprised five items addressing support, recognition, adequate payment, workers’ trust in the management, and the management's trust in workers, as perceived by the workers. WV captured job security, promotion prospects and job latitude by three items. Hair cortisol concentrations (HCC) were analyzed by liquid chromatography–mass spectrometry. Stepwise multivariable linear regression models (backward elimination of predictors) were used to estimate associations of HCC with the three work stress components. For significant work stress component(s), further multivariable linear regression analyses were conducted to explore whether, and if so, which individual item(s) contributed most.The mean HCC equaled 3.27 (SD 2.58) pg/mg. HCC were found to be significantly associated with WV (beta=0.209, p=0.021). Additional analyses of the three WV items revealed that this association was largely driven the item on “promotion prospects” (beta=0.230, p=0.007) implying that the perception of good promotion prospects was associated with higher HCC.The finding of elevated HCC with good promotion prospects may initially seem counter-intuitive, but is supported by research documenting that job promotion may result in poorer mental well-being. Moreover, being promoted in the Bangladeshi RMG industry may represent a stressful experience: job promotions are rare in this setting and are associated with the need to meet exceptional job-related demands. Further research from ethnic and culturally diverse occupational settings is needed to test this hypothesis, to shed light on the reproducibility of our findings and to improve our understanding of the psychobiological implications of psychosocial working conditions across cultures and contexts

Evidence for a massive BH in the S0 galaxy NGC 4342

We present axisymmetric dynamical models of the edge-on S0 galaxy NGC 4342. A combination of observations from the ground and with the Hubble Space Telescope (HST) has shown that NGC 4342 rotates rapidly and has a strong central increase in velocity dispersion. We construct simple two-integral Jeans models as well as fully general, three-integral models. The latter are built using a modified version of Schwarzschild's orbit-superposition technique. The two-integral Jeans models suggest a black hole (BH) mass between 3 and 6x10^8 Msun, depending on the data set used to constrain the model, but they fail to fit the details of the observed kinematics. The three-integral models can fit all ground-based and HST data simultaneously, but only when a central BH is included. Models without BH are ruled out to a confidence level better than 99.73 per cent. We determine a BH mass of 3x10^8 Msun. This corresponds to 2.6 per cent of the total mass of the bulge, making NGC 4342 one of the galaxies with the highest BH mass to bulge mass ratio currently known. The models that best fit the data do not have a two-integral phase-space distribution function. They have rather complex dynamical structures: the velocity anisotropies are strong functions of radius reflecting the multi-component structure of this galaxy. The best fit model without BH tries to fit the high central velocity dispersion by placing stars on radial orbits. The measured rotation velocities, however, restrict the amount of radial anisotropy such that the central velocity dispersion measured with the HST can only be fit when a massive BH is included in the models.Comment: 47 pages, 14 figures (postscript). Submitted to Ap

Pattern formation in 2-frequency forced parametric waves

We present an experimental investigation of superlattice patterns generated on the surface of a fluid via parametric forcing with 2 commensurate frequencies. The spatio-temporal behavior of 4 qualitatively different types of superlattice patterns is described in detail. These states are generated via a number of different 3--wave resonant interactions. They occur either as symmetry--breaking bifurcations of hexagonal patterns composed of a single unstable mode or via nonlinear interactions between the two primary unstable modes generated by the two forcing frequencies. A coherent picture of these states together with the phase space in which they appear is presented. In addition, we describe a number of new superlattice states generated by 4--wave interactions that arise when symmetry constraints rule out 3--wave resonances.Comment: The paper contains 34 pages and 53 figures and provides an extensive review of both the theoretical and experimental work peformed in this syste

Monitoring the spread of meticillin-resistant Staphylococcus aureus in The Netherlands from a reference laboratory perspective

SummaryBackgroundIn The Netherlands, efforts to control meticillin-resistant Staphylococcus aureus (MRSA) in hospitals have been largely successful due to stringent screening of patients on admission and isolation of those that fall into defined risk categories. However, Dutch hospitals are not free of MRSA, and a considerable number of cases are found that do not belong to any of the risk categories. Some of these may be due to undetected nosocomial transmission, whereas others may be introduced from unknown reservoirs.AimIdentifying multi-institutional clusters of MRSA isolates to estimate the contribution of potential unobserved reservoirs in The Netherlands.MethodsWe applied a clustering algorithm that combines time, place, and genetics to routine data available for all MRSA isolates submitted to the Dutch Staphylococcal Reference Laboratory between 2008 and 2011 in order to map the geo-temporal distribution of MRSA clonal lineages in The Netherlands.FindingsOf the 2966 isolates lacking obvious risk factors, 579 were part of geo-temporal clusters, whereas 2387 were classified as MRSA of unknown origin (MUOs). We also observed marked differences in the proportion of isolates that belonged to geo-temporal clusters between specific multi-locus variable number of tandem repeat analysis (MLVA) clonal complexes, indicating lineage-specific transmissibility. The majority of clustered isolates (74%) were present in multi-institutional clusters.ConclusionThe frequency of MRSA of unknown origin among patients lacking obvious risk factors is an indication of a largely undefined extra-institutional but genetically highly diverse reservoir. Efforts to understand the emergence and spread of high-risk clones require the pooling of routine epidemiological information and typing data into central databases

Isospin Dependence in the Odd-Even Staggering of Nuclear Binding Energies

The FRS-ESR facility at GSI provides unique conditions for precision measurements of large areas on the nuclear mass surface in a single experiment. Values for masses of 604 neutron-deficient nuclides (30<=Z<=92) were obtained with a typical uncertainty of 30 microunits. The masses of 114 nuclides were determined for the first time. The odd-even staggering (OES) of nuclear masses was systematically investigated for isotopic chains between the proton shell closures at Z=50 and Z=82. The results were compared with predictions of modern nuclear models. The comparison revealed that the measured trend of OES is not reproduced by the theories fitted to masses only. The spectral pairing gaps extracted from models adjusted to both masses, and density related observables of nuclei agree better with the experimental data.Comment: Physics Review Letters 95 (2005) 042501 http://link.aps.org/abstract/PRL/v95/e04250